2021E/M Guidelines020WDLGSP34A-11

No part of this document may be reproduced or transmitted in any form or by any means, electronic ormechanical, for any purpose, without the express written permission of Weston Distance Learning, Inc.Copyright 2021, Weston Distance Learning, Inc. All Rights Reserved.020WDLGSP34A-11AcknowledgmentsCourtney Pruitt-Sanderson, M.Ed., RHIA, AuthorBrenda Blomberg, B.A., CPC, Author/Curriculum Project ManagerMary Siegrist, PhD, RHIA, Subject Matter ExpertSa’mone Dixon, Subject Matter ExpertEditorial StaffLeslie Ballentine, M.S., Dean of CurriculumHeather Deibert, B.S., CPC, Academic Content EditorJamie Schenkel, Editorial AssistantJessica Babb-Raymundo, B.A., Graphic DesignerFort Collins, CO

Table of ContentsIntroduction. 5Office or Other Outpatient Services. 5Time Component. 6Prolonged Service Code. 8Medical Decision Making Component. 9Practice Exercise 1. 14Review Practice Exercise 1. 16Endnotes. 17

2021 E/M GuidelinesIntroductionDocumentation establishes the level of service for an evaluation and management code. In 1995, CMS(known as the Health Care Financing Administration at that time) established guidelines for documentation,known as the 1995 Guidelines. To encourage more detailed documentation to better support the level ofservice billed, CMS created the 1997 Guidelines. The history and medical decision-making componentsremained the same, but the examination component went through quite a transformation. The 1995Guidelines recognized organ systems and body areas for the purpose of obtaining an overall examinationlevel. The 1997 Guidelines established a multisystem examination as well as various single-organexamination requirements. However, many professionals in the medical field felt that the 1995 Guidelineswere less cumbersome, and the 1997 Guidelines were missing valid details. Therefore, CMS determined thatcarriers are to continue reviews using either the 1995 or 1997 Documentation Guidelines for Evaluation andManagement Services (whichever is more advantageous to the physician) until further notice. Because the1995 Guidelines are more widely used and straightforward to work with, those are the guidelines used inyour course materials.In 2021, the AMA has revised the guidelines and element scoring for new and established patients (9920299215). The information provided in your course materials still applies to all codes using key components,except for codes 99202-99215. Please complete your course using the guidelines and processes provided inyour course materials. If you are using a 2021 CPT coding manual, you’ll note that codes 99201-99215 havebeen deleted from the Evaluation and Management section. However, you can still access the informationyou need as the deleted codes can be found in Appendix B. To assist you in learning the 2021 revisedguidelines for 99202-99215, we created a supplement to walk you through the process of coding office visitfor new and established patients.Office or Other Outpatient ServicesThese codes are for office visits and are categorized by the patient status. You’ll recall that a new patient isone who has not received any professional services from the physician or qualified healthcare professional oranother physician or qualified healthcare professional of the exact same specialty and subspecialty who belongsto the same group practice, within the last three years. When the documentation indicates “initial office visit,”you will be coding for a new patient office visit.Prior to 2021, medical coders typically used the 1995 Guidelines with key components to determine the overalllevel of service for both new and established office visits. However, the American Medical Association (AMA)was committed to changing the coding and documentation requirements for office E/M visits to simplifythe work of the healthcare provider and to improve patient care. To decrease the administrative burden ofdocumentation, the AMA removed the counting process for history and examination. This also decreased theunnecessary documentation requirements that are not needed for patient care.

2021 E/M GuidelinesAccording to the 2021 Guidelines, the provider should document a medically appropriate history and/orexamination for office visits, and the overall level of services can be determined using either medical decisionmaking or the total time spent on the date of the encounter. Note, the documented history and/or exam isnot used in the code level selection. Furthermore, “medically appropriate” means what the provider feels isnecessary for patient care should be documented.Time ComponentWith the 1995 Guidelines, time is used to assign an evaluation and management code only when thephysician spends more than 50 percent of the time face-to-face with the patient and/or family. In 2021, theAMA changed the definition of time as it relates to office visits (99202-99215).Prior to 202199203 Office or other outpatient visit for theevaluation and management of a new patient,which requires these 3 key components: A detailed focused history; A detailed examination; Medical decision making of low complexityCounseling and/or coordination with otherphysicians, other qualified healthcareprofessionals, or agencies are provided consistentwith the nature of the problem(s) and thepatient’s and/or the family’s needs.Begin in 202199203 Office or other outpatientvisit for the evaluation andmanagement of a new patient,which requires a medicallyappropriate history and/orexamination and low level ofmedical decision making.When using time for codeselection, 30-44 minutes of totaltime is spent on the date of theencounter.Usually the presenting problem(s) are of low tomoderate severity. Typically, 30 minutes are spentface-to-face with the patient and/or family.99213 Office or other outpatient visit for theevaluation and management of a newpatient, which requires at least 2 of these 3 keycomponents: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexityCounseling and/or coordination with otherphysicians, other qualified healthcareprofessionals, or agencies are provided consistentwith the nature of the problem(s) and thepatient’s and/or the family’s needs.99213 Office or other outpatientvisit for the evaluation andmanagement of a new patient,which requires a medicallyappropriate history and/orexamination and low level ofmedical decision making.When using time for codeselection, 20-29 minutes of totaltime is spent on the date of theencounter.Usually the presenting problem(s) are of low tomoderate severity. Typically, 15 minutes are spentface-to-face with the patient and/or family.6020WDLGSP34A-11

2021 E/M GuidelinesWhen coding office visits for new or established patients (99202-99215), time is the total time spent with thepatient on the date of the encounter. Time may be used to select a code level for office visits, whether or notcounseling and/or coordination of care dominates the service. Note that a key shift for the office visit codesis that the time referenced is the total time, which includes both face-to-face and non-face-to-face time spentby the provider on that encounter day. When determining the cumulative time, you should not include timespent on services that are reported separately. For instance, if you report care coordination using a separateCPT code, you should not include that in the time for the E/M code. In addition, the total time also will notinclude time for activities the clinical staff normally performs.Physician and/or other qualified healthcare professional time for office visits includes the following activities: Preparing to see the patient (eg, review of tests) Obtaining and/or reviewing separately obtained history Performing a medically appropriate exam and/or evaluation Counseling and educating the patient, family or caregiver Ordering medications, tests or procedures Referring and communicating with other healthcare professionals (when not reported separately) Documenting clinical information within the medical record Independently interpreting results (when not reported separately) and communicating results tothe patient, family or caregiver Care coordination (when not reported separately)Time includes communicating with other healthcare professionals.Currently, there is no guideline as to how the time must be documented in the medical record other than thetotal time is to be noted. The cumulative time must be from the calendar day of the encounter; it does notcarry over from the previous or to the following day. Finally, clear time ranges are established for each code.99202992039920499205020WDLGSP34A-1115-29 minutes30-44 minutes45-59 minutes60-74 minutes9921299213992149921510-19 minutes20-29 minutes30-39 minutes40-54 minutes7

2021 E/M Guidelines2021 CPT UpdateThe AMA deleted codestraightforward MDM;you may still reporthave not adopted the99201 because codes 99201 and 99202 both required aonly code 99202 remains. There are some situations in which99201, such as for workers’ compensation or payers that2021 CPT changes.The time component for code 99211 was removed in 2021. Code 99211 is for the evaluation andmanagement of an established patient that may not require the presence of a physician or other qualifiedhealthcare professional. Usually, the presenting problem(s) are minimal. This patient is usually assisted bythe clinician and does not see the provider directly.Prolonged Service CodeIn addition to the clear time ranges for office visits, a prolonged service code was created to capture servicesfor a patient that requires longer time on the date of the encounter. While the typical patient with a runnynose may require a 15-minute appointment, the patient with additional questions, prompted from onlineresearch or a worried family member, may require a longer visit to answer these questions.Some family members may have more time.Prolonged services (99417) are to be reported when the visit is based on time and after the total time of thehighest-level service (99205/99215) has been exceeded. This code allows for face-to-face and non-face-toface care on the date of the encounter. However, this code should not be used for any time unit less than 15minutes.99205 Total Time 75 minutes75-89 minutes90-104 minutes8Code(s)Not reported separately99205 1 99417 199205 1 99417 299215 Total TimeCode(s) 55 minutesNot reported separately55-69 minutes99215 1 99417 170-84 minutes99215 1 99417 2020WDLGSP34A-11

2021 E/M GuidelinesMedical Decision Making ComponentYou’ve already studied medical decision making when you explored the key components for the 1995Guidelines. However, in 2021, the AMA removed ambiguous terms, provided terminology definitions andused the 1995 Guidelines Table of Risk as a foundation to create the 2021 Guidelines Level of Medical DecisionMaking Table. The goal of the new table is to reduce variation, align with clinically intuitive concepts andreduce disruption in the current coding patterns. You will see similarities to the MDM component you studiedpreviously. Remember, you will not use the 2021 Guidelines for anything other than codes 99202-99215.Now, let’s look at the 2021 Guidelines Level of Medical Decision-Making Table that is used to determine thelevel of service for office visits. Similar to the 1995 Guidelines, there are three parts to the MDM table: Number and Complexity of Problems Addressed at the Encounter Amount and/or Complexity of Data to be Reviewed and Analyzed Risk of Complications and/or Morbidity or Mortality of Patient ManagementAlthough these elements may seem like the 1995 table, they are different and should not be confused. Whencoding for an office visit (99202-99215) you are to use the 2021 Guidelines Level of Medical Decision-MakingTable. Any other E/M codes that require the use of 1995 Guidelines will use the MDM table.Number and Complexity of Problems Addressed at the EncounterFirst, you will consider the problem that is addressed or managed when it is evaluated or treated at theencounter by the provider. This includes consideration of further testing or treatment that may not be electedby the patient and/or family. However, noting a problem without documenting additional assessment orcare coordination does not count. According to the guidelines, comorbidities or underlying diseases, in and ofthemselves, are not considered in selecting a level of E/M Services unless they are addressed, and their presenceincreases the amount and/or complexity of data to be reviewed and analyzed or the risk of complication and/or morbidity or mortality of patient management. For instance, if the PCP notes the patient’s congestive heartfailure is managed by the cardiologist, the PCP does not count that as a problem that was addressed duringthis encounter, unless how it affects the treatment plan is documented.Definitions for the elements of MDM are included in the E/M Guidelines. Here are some highlights of thosedefinitions: Self-limiting or minor problem. A problem that runs a definite and prescribed course, is transient innature and is not likely to permanently alter health status. Stable, chronic illness. A problem with an expected duration of at least a year or until the death ofthe patient. Stable—Defined by the specific treatment goals for an individual patient. A patient who is not attheir treatment goal is not stable, even if the condition has not changed and there is no short-termthreat to life or function. For example, a patient with persistently, poorly controlled blood pressurefor whom better control is a goal is not stable, even if the pressures are not changing and the patient isasymptomatic. The risk of morbidity without treatment is significant. Chronic—Conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolleddiabetes and controlled diabetes are a single chronic condition).020WDLGSP34A-119

2021 E/M Guidelines Acute, uncomplicated illness or injury. A recent or new short-term problem with low risk of morbidityfor which treatment is considered. There is little to no risk or mortality with treatment, and full recoverywithout functional impairment is expected. For example, a problem that is normally self-limited or minor,but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.When using the table, only one item needs to be selected to meet that level of service. For instance, one acute,uncomplicated illness meets the requirements for low complexity for problems addressed at the encounter.MinimalLow 1 self-limited or 2 or more selfminor problemlimited or minorproblems 1 stable, chronicillness 1 acute,uncomplicatedillness or injuryModerate 1 or more chronic illnesseswith exacerbation,progression or side effectsof treatment 2 or more stable, chronicillnesses 1 undiagnosed newproblem with uncertainprognosis 1 acute illness with systemicsymptoms 1 acute complicated injuryHigh 1 or morechronic illnesseswith severeexacerbation,prognosis orside effects oftreatment 1 acute or chronicillness or injury thatposes a threatto life or bodilyfunctionAmount and/or Complexity of Data to be Reviewed and AnalyzedAccording to the CPT, the data here includes medical records, tests and/or other information that must beobtained, ordered, reviewed and analyzed for the encounter. However, if you are reporting the service with itsown CPT code, you won’t count it here. For instance, if your office does its own x-rays and you submit a codefrom the radiology section with the claim, you will not count that as data here. Essentially, the data is dividedinto three categories: Tests, documents, orders or independent historian(s). Each unique test, order or document is counted. Independent interpretation of tests not reported separately. Discussion of management or tests interpretation with external physician or other qualified healthcareprovider or appropriate source (not reported separately).For this element of the MDM, minimal or no data is straightforward, while two documents or independenthistorian are low. For moderate, you must have one category from count, interpret or confer. Count refers to documenting notes, tests, orders and independent historian(s). Notes refers to thedocuments reviewed are from external sources—not your last appointment with the patient. Tests applywhen reviewing radiology, pathology and medicine tests. Finally, order indicates the provider requesteda radiology, pathology or medicine test. An independent historian is an individual (eg, parent, guardian,surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who isunable to provide a complete or reliable history (eg, due to developmental stage, dementia or psychosis)or because a confirmatory history is judged to be necessary.110020WDLGSP34A-11

2021 E/M Guidelines Interpret refers to an independent interpretation of test(s) performed by another provider. In manyhealthcare centers, a number of specialists may be grouped together, allowing the specialist to worktogether in the patient care. For instance, your PCP suspects you have a fractured wrist and wants anx-ray to confirm this. Luckily, the diagnostic center is two floors up and you’re able to get in right away.After the x-ray, you return to the PCP’s office. The staff alerts the PCP that you’ve returned, so he logsinto your electronic record and is able to view your x-ray right then. While the radiologist will read thex-ray and provide their results (and bill you for the professional service), your PCP has provided anindependent interpretation of the test. Confer refers to the discussion of management or test interpretation with an external provider.For instance, the PCP determines his patient with the fractured wrist would benefit from seeing anorthopedic surgeon for the repair. The PCP contacts an orthopedic surgeon, discusses the situation andreviews the x-ray together. The surgeon agrees to take the case and the PCP refers the patient for furthertreatment.Minimal or None NoneLimited(must meet 1 of 2) Historian Count (2)Notes xTests xOrder xModerateExtensive(must meet 1 of 3) (must meet 2 of 3) Count (3) Count (3)Notes xNotes xTests xTests xOrder xOrder xHistorianHistorian Interpret Interpret Confer ConferNote, when a combination of two are required in the counting and the provider orders two unique tests, therequirements of this category have been met. Although each has its own CPT code, you are reviewing theresults or ordering the test, not billing for doing the test.Let’s look at an example for clarification. Dr. Bates orders a CBC and a chest x-ray. Two tests are ordered fora count of two, and limited must meet one element; therefore, limited has been met. Now, say that Dr. Batesorders a CBC, a comprehensive metabolic panel and the chest x-ray, there’s a count of three which meetsthe moderate level of service. If Dr. Bates orders the x-ray and interprets the results himself in addition toordering the CBC and comprehensive metabolic panel, you have a count of three plus another category,which meets the extensive level of service.Risk of Complications and/or Morbidity or Mortality of Patient ManagementThe final element of the MDM looks at the risk of complications, morbidity and/or mortality of patientmanagement decisions made at the visit, associated with the patient’s problem(s) the diagnostic procedure(s) andtreatment(s), according to the E/M Guidelines. This includes the possible management options selected andthose considered but not selected after shared medical decision making with the patient and/or family. Thismay include the decision for palliative treatment rather than hospitalizing a patient with advanced dementiawith an acute condition that generally warrants inpatient care. The provider may also address risks associatedwith social determinants of health. Social determinants of health are economic and social conditions thatinfluence the health of people and communities.2 Examples may include food or housing insecurity. Forinstance, the provider may document that Drug A would be beneficial to the patient, but because the patientdoesn’t have insurance, the less expensive Drug B will be prescribed.020WDLGSP34A-1111

2021 E/M GuidelinesONLINE LEARNINGBuild on what you are learning by reading more about socialdeterminants of health at es/topic/social-determinants-of-health.Minimal Minimal riskof morbidityfrom additionaldiagnostictesting ortreatmentLow Low risk ofmorbidity fromadditionaldiagnostictesting ortreatmentModerateHigh Moderate risk High risk ofof morbiditymorbidity fromfrom additionaladditionaldiagnosticdiagnostictesting ortesting ortreatmenttreatmentLet’s look at the details of these levels. For straightforward, there is minimal risk from the treatment ortesting. You will select this level when there is no treatment required for the service. Low risk, on the otherhand, has very low risk of severity problems and often minimal consent or discussion is required.The E/M Guidelines offer examples for moderate and high risk, so be sure to reference it when coding fromthis section. With moderate risk, the provider typically discusses the risk with the patient and/or familyor obtains consent and monitors the treatment. Examples for this level of risk include prescription drugmanagement; decision regarding minor surgery with identified risk factors; decision regarding electivemajor surgery without identified risk factors; and diagnosis or treatment significantly limited by socialdeterminants of health.High level of risk are services in which the provider needs to discuss higher risk problems that could happen,and the provider will need to monitor the treatment. Examples for this level of risk include drug therapyrequiring intensive monitoring for toxicity; decision regarding elective major surgery with identified riskfactors; decision regarding emergency major surgery; decision regarding hospitalization; and decision not toresuscitate or to de-escalate care because of poor prognosis.Overall MDMTo qualify for a particular level of medical decision making, two of the three elements for that level ofdecision making must be met or exceeded. For instance, you have the Number and Complexity of ProblemsAddressed at the Encounter (Dx) at low; the Amount and/or Complexity of Data to be Reviewed and Analyzed(Data) at moderate; and Risk of Complications and/or Morbidity or Mortality of Patient Management (Risk)at high. You’ll drop the lowest and use the other two to determine the MDM level. At this point, you’ll selectthe lower of the remaining two, which is the moderate for Data. Your overall MDM is Moderate nsivehigh020WDLGSP34A-11

2021 E/M GuidelinesLet’s walk through an example of an office visit for an established patient.SUBJECTIVEThe patient is a 2-year-old male. The mother states she was called to pick her son up from the preschool, because hehad a low-grade fever, sore throat with blisters in his mouth and refused to eat.OBJECTIVEA vesicular exanthema is distributed over the buccal mucosa and palate with similar lesions on the hands and feet andin the diaper area. Rectal temperature: 103 ºF. A rectal swab specimen was ordered, and the results were positive forCoxsackie A virus.ASSESSMENTHand, foot and mouth disease.PLANTylenol with codeine prescribed for pain and fever. Bed rest. Encourage increase in fluid intake, including milk, liquidgelatin, ice cream, custard or drinks made with syrup of wild cherry (available at pharmacy). Prevent exposure to otherinfants and young children and any persons with a respiratory illness. Symptoms should subside in 4-5 days, and thenhe can return to school.To code this report, the provider must indicate a medically appropriate history and/or exam, which has beendone. For this service, the provider has selected to code by MDM rather than time, so you’ll refer to themedical decision-making table. Let’s walk through the process.First, consider the number and complexity of the problem addressed at the encounter. The patient has hand,foot and mouth disease. If you refer back to the definitions, this recent or new short-term problem with lowrisk of morbidity for which treatment is considered. There is little to no risk or mortality with treatment,and full recovery without functional impairment is expected. Therefore, it is an acute, uncomplicated illness,which is low for the problem addressed.Next, you’ll look at the amount and/or complexity of the data to be reviewed and analyzed. The providerordered and reviewed the results of the rectal swab. You see that under tests and documents, the provider cando a combination of any two. The provider ordered a test (1) and reviewed the results of that test (1). Becauseboth are documented and not billed by the provider, you can count both for this element. The provider didnot indicate interpreting the results so you’ll stop there. This count results in a limited level for data.Finally, you’ll look at the risk of complications and/or morbidity or mortality of patient management. Yousee that the provider prescribed Tylenol with codeine, which is an example of prescription drug managementfound under the moderate level of ghextensivehighTo determine the overall level, you only need to consider two of the three elements. In this case, two of thethree are low, so your overall level will be low as well. You’ll code 99213 for this established office visit.020WDLGSP34A-1113

2021 E/M GuidelinesAs long as the provider performs a medically appropriate history and/or physical examination; indicates thelevel of medical decision making performed or the total time spent performing the service; and documentsthem as if she were there—and meets the basic conditions of a telemedicine visit—then you have a billableevaluation and management visit. Keep in mind that Medicare and most large commercial payers will acceptthe code with modifier 95. The place of service might be where the services normally take place, such as thephysician’s office, or the insurance carrier may require the telehealth code for the place of service.Practice Exercise 1Determine if each statement is true or false.1. Telehealth services can be provided using just audio.2. The provider should document the history and examination information he feels is necessaryfor patient care.3. To determine the overall level of service for an office visit, you will consider both the MDM andtotal time on the date of the encounter.4. Time spent the day before and day after the service are considered when coding with time.5. Activities usually performed by the clinical staff is included in the total time.6. Care coordination is included in the total time when not reported separately.7. Number and complexity of problems addressed at the encounter includes consideration of furthertesting or treatment that may not be elected by the patient and/or family.8. An acute, uncomplicated illness is a problem that runs a definite and prescribed course, is transientin nature and is not likely to permanently alter health status.9. For the data element of the MDM, each unique test, order or document is counted.10. Those treatment options considered but not selected after shared medical decision making withthe patient and/or family help determine the risk.Answer as directed.11. Marj is coding a medical record for an established office visit based on the level of medicaldecision making, as directed by the practice guidelines. She determines the service is 99213 basedon the documentation. However, the provider notes that the service was 45 minutes long. The timerage for code 99213 is 20-29 minutes; therefore, Marj add the prolonged service code (99417) toindicate the service exceeded the time for code 99213. She submits codes 99213 and 99417 for thisservice. Was this correct?14020WDLGSP34A-11

2021 E/M GuidelinesRead the following scenarios and use the forms found in your E/M Audit for Practices Exercises to answer asdirected.12. Initial Office VisitSUBJECTIVETwo weeks ago, the mother of this 7-year-old female noted a low-grade fever, headache and stuffy nose lasting 3 days.A couple of days after symptoms subsided, patient noticed a bright red rash on her face. Patient now presents withsimilar rash on trunk, arms and legs x 1 week.OBJECTIV

Medical Decision Making Component You've already studied medical decision making when you explored the key components for the 1995 Guidelines. However, in 2021, the AMA removed ambiguous terms, provided terminology definitions and used the 1995 Guidelines Table of Risk as a foundation to create the 2021 Guidelines Level of Medical Decision-